understand that I am voluntarily opting to come into the office for an evaluation, treatment, procedure or surgery that is not urgent and may not be medically necessary.
I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Dr’s Zimmerman, Lee and Rodriguez and all the staff at Aesthetic Revolution Las Vegas are closely monitoring this fluid situation and have, and will continue, put in place reasonable preventative measures per the recommendations of the Center for Disease Control and other health authorities, aimed to reduce the spread of COVID-19.
However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with any elective office visits, treatment, procedures or surgeries. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for the doctors and all the staff at Aesthetic Revolution Las Vegas to proceed with the same.
I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective office visit, treatment, procedure or surgery can lead to a higher chance of complication and death.
I understand that possible exposure to COVID-19 before/during/after my office visit, treatment, procedure or surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective office visit, treatment, procedure or surgery, I may need additional care that may require me to go to an emergency room or a hospital.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the office visit, treatment, procedure or surgery itself.
I have been given the option to defer my office visit, treatment, procedure or surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired office visit treatment, procedure or surgery.
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE.
I have been offered a copy of this consent form.
consent to receive elective aesthetic procedures from Aesthetic Revolution Las Vegas during the COVID-19 outbreak.
I understand there is much to learn about who the COVID-19 virus spreads and is transmitted.
I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19
I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment in the practice.
I understand that under the CDC guidelines, do not recommend proceeding with any treatment that is non-essential at this time.
I understand that the treatment I am receiving is NOT a medical emergency. It is an elective treatment.
I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread.
I understand that the symptoms listed below are representative of COVID-19:
I confirm that I do not display or currently have any of the symptoms that are representative of COVID- 19, which are outlined above: (Initial)
I understand that all travelers arriving from a country or region with widespread ongoing transmission, as outlined by the CDC, should stay home for 14 days to practice social distancing and monitor their health after their arrival.
I confirm that I have not traveled to any of the countries or regions with widespread ongoing transmission (Level 3 Travel Health Notice) in the past 14 days
I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.